OMB No. 1545-0074Form

2120

(Rev. October 2005)

Multiple Support Declaration

AttachmentSequence No.114Department of the Treasury

Internal Revenue ServiceAttach to Form 1040 or Form 1040A.

Your social security numberName(s) shown on return

During the calendar year, the eligible persons listed below each paid over 10% of the support of:

Name of your qualifying relative

I have a signed statement from each eligible person waiving his or her right to claim this person as a dependent for any tax year

that began in the above calendar year.

Social security numberEligible person’s name

Address (number, street, apt. no., city, state, and ZIP code)

Form2120(Rev. 10-2005)Cat. No. 11712F

Social security numberEligible person’s name

Address (number, street, apt. no., city, state, and ZIP code)

Social security numberEligible person’s name

Address (number, street, apt. no., city, state, and ZIP code)

Social security numberEligible person’s name

Address (number, street, apt. no., city, state, and ZIP code)

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